Time trade-offs in advanced ovarian cancer.
Mukamel DB, Cohn DE, Havrilesky L, Wright AA, Lipscomb J, Sparks L, Ladd H, Osann K
J Clin Oncol 34 20 10/09/2016
20 Background: Most women with advanced ovarian cancer develop recurrence and die within five years of diagnosis. This creates a clinical imperative to discuss tradeoffs between the risks and benefits of treatment options. The purpose of this study is to examine the experience of ovarian cancer patients presented with a decision aid leading them through a time-tradeoff (TTO) exercise to guide choice of therapy.
METHODS : Newly diagnosed advanced ovarian cancer patients (N = 64) participated in a study evaluating the effectiveness and usefulness of a Patient-Centered Outcome Aid (PCOA). This i-Pad based interactive aid included an exercise during which patients evaluated personal tradeoffs between longer survival and adverse events associated with chemotherapy, in consultation with providers. Patients were educated about potential side effects, asked to rank their concerns about each side effect, and then asked: "Now that you have thought about and ranked the side effects, we ask you to think about the worst side effect for you as it relates to survival in good health. Would you be willing to go through 6 months of your worst side effect, if it gave you 5 years of good health?" There was a forced choice (Yes vs. No); then the tradeoff question was repeated with decreasing survival times: i.e. 3 years, 1 year, and 9, 6, 5, 4, 3, 2, and 1 months.
RESULTS : Of the 61 patients who responded to the TTO question, 52% required 1 or more years of good health to endure 6 months of their worst side effect. Among the non-neoadjuvant patients (N = 50), 18% indicated they would trade 6 months of the worst side effect for 1-2 months of additional life in good health, however 56% would require 9 months or more. While 95% of patients found it easy to rank order concerns about side effects, 75% considered the TTO question difficult to answer.
CONCLUSIONS : Decisions aids which incorporate tradeoffs must be designed with sensitivity to differential health literacy levels, and the extremely personal nature of this decision.